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January 25, 2018

Four Tests Added to List of CLIA Waived Tests

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Medical Coding News Archives

CMS Clarifies Outpatient Psych Payment Limitation

March 18, 2011:
A recent transmittal to Medicare contractors explains what ICD-9-CM codes are related disorders to Alzheimer’s disease. This is important since the treatment of the disease is NOT subject to an outpatient payment limit.

When the primary treatment of a patient with a diagnosis of Alzheimer’s disease or a related disorder is psychotherapy, it is subject to an outpatient payment limitation. However, typically, medical management of the patient’s condition (such as that described under CPT code 90862 or any successor code) is not subject to the outpatient limit. Therefore, when a claim is received with the diagnosis of Alzheimer’s disease (ICD-9-CM code 331.0), the Centers for Medicare and Medicaid Services (CMS) instructs Medicare contractors to look to the nature of the service rendered in determining whether the service provided is subject to the limitation. However, contractors must also identify any Alzheimer’s related disorders that are within the 290-319 code range (290.XX or others as contractors determine appropriate) or outside the 290-319 code range as determined appropriate by contractors.

Medicare payment treating mental, psychoneurotic, and personality disorders while the patient is not an inpatient of a hospital is limited to 62.5 percent of the Medicare approved amount for those services. This limitation is called the outpatient mental health treatment limitation. However, it should be noted that this limitation, while in effect since the inception of the Medicare Part B program, started being phased out beginning January 1, 2010. Effective January 1, 2010, through January 1, 2014, the limitation amounts are as follows:
  • January 1, 2010 – December 31, 2011, the limitation percentage is 68.75%. (Medicare pays 55% and the patient pays 45%.)
  • January 1, 2012 – December 31, 2012, the limitation percentage is 75%. (Medicare pays 60% and the patient pays 40%).
  • January 1, 2013 – December 31, 2013, the limitation percentage is 81.25%. (Medicare pays 65% and the patient pays 35%).
  • January 1, 2014 – onward, the limitation percentage is 100%. (Medicare pays 80% and the patient pays 20%).

Deborah C. Hall
Clinical/Technical Editor


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